How to Chart Smarter and Optimize for the Best

Time is valuable in emergency medicine. Here’s how those costs might be hitting your wallet.

Critical Care services account for about 8% of the total revenue derived in a typical Emergency Department.(1) In caring for “sick” patients, it’s likely a large portion of the service you provide. That said, every year more than $160,000,000 is estimated left on the table by emergency clinicians. A sizable portion of this unrealized reimbursement occurs as a result of inadequate documentation.(2) For a typical ED group, optimizing your total Critical Care by just a few percentage points can increase annual revenue by many tens of thousands of dollars.(3) In this article, you’ll learn how to optimize the financial return for the Critical Care services you provide.

Understand the Fundamentals of Critical Care:

Critical Care Time involves time spent on providing services to a critically ill or injured patient. The 2018 AMA CPT codebook describes a critical illness or injury as one that “acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.”(4) It’s easy to see how an emergency encounter involving a 72-year-old male with severe lower back pain, a pulsatile abdominal mass and hypotension will likely quality for Critical Care time. However, there are many other cases involving much more indolent presentations which still end up qualifying for Critical Care.

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To demonstrate one of these subtle encounters, consider this hypothetical case. A 42-year-old diabetic female presents with unilateral back pain, hematuria and a low grade fever. Your work up reveals she has urinary sepsis in the setting of an obstructing ureter stone. Your management here will likely involve a number of life-saving interventions, which qualify this case for Critical Care time. While she may have presented with a non-toxic appearance and quasi-stable vital signs, the serious nature of her illness unfolded over her ER course. In cases such as this, be sure to recognize the value of your service.

In another example, a 23-year-old asthmatic male presents acutely dyspneic with accessory muscle usage and is seen through your Fast Track. His history is significant for being intubated for asthma six months prior. During this encounter, he receives three re-exams, a few rounds of albuterol/atrovent nebs as well as solumedrol and magnesium sulfate IV. Chest X-ray reveals hyperinflation without pneumothorax or infiltrate. After three hours, he feels better and is discharged home. What to keep in mind here: Don’t allow the treatment room to dictate or over-shadow your level of service. If you spent 30 minutes or more caring for this patient, this case qualifies for Critical Care time.

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Interestingly, as with the encounter above, your Critical Care service does not hinge on your disposition. You can reimburse for Critical Care service even when a patient is ultimately discharged home. This does not happen often, though it does occur. In any event, you must include a Critical Care statement. Be sure to document this, and you’ll optimize your reimbursement.

Caveats of Critical Care Time

Some caveats in Critical Care billing:
1) The physician or advanced practice clinician must be providing the service exclusively towards the patient during their overall documented time of care.
2) Time spent related to the patient’s care can occur at the bedside or elsewhere on the unit as long as the provider is “immediately available” to the patient.

Thus, Critical Care service does not have to occur exclusively “face-to-face” with the patient. Your discussions with paramedics and/or family regarding the patient’s care applies towards Critical Care — even though you may be away from the bedside. Additionally, your time with computer order entry, reviewing imaging/reports, consulting with primary and specialty physicians, and charting all count towards Critical Care time.

These figures are based on an average of 1 RVU = $ 36.00 according to the 2018 Medicare Physician Fee (precise amount, geographic specific).(5) Thus, the difference in reimbursement is $50.76 and may be even higher with your private insurers. When Critical Care services are warranted and rendered, these gains are realized simply by documenting a Critical Care statement.

Many Emergency Medicine physicians and advanced practice clinicians fail to document the Critical Care services they provide. This is a missed opportunity for appropriate reimbursement. Why settle for sub-optimal? When appropriate, be sure to document your corresponding Critical Care time and receive the proper reimbursement for the work you do.

30 Minutes = Your Breakthrough Time in Critical Care

“I spent 30 minutes of critical care time with this patient. This does not include time spent on separately reported billable procedures.”

This is the marquee statement in regards to Critical Care documentation. In order to receive specific reimbursement, this statement must be documented. Thirty minutes is the threshold at which a specific charge can be submitted by your coders. Moreover, a distinct charge is billed for Critical Care services provided at 30, 75, 105 minutes and increments of every additional 30 minutes.

Exclusionary Statement are Essential

An “exclusionary statement” is required by AMA CPT Guidelines that indicates your Critical Care time did not include “separately reported billable procedures.” Procedures such as intubation, chest tubes, central lines and CPR cannot be counted towards Critical Care time. These are “separately reported billable procedures.” However, patients undergoing these procedures often do require 30 minutes or more of Critical Care time due to the serious nature of their illness. Remain attentive and be aware of the complete service you provide.

Be Mindful of Your Time

You’ll find time goes by quickly when caring for critically ill patients. With your next potentially sick patient, as you pick up the chart, note the time on your watch. Write this down. Next, when you are done with your initial evaluation and care of the patient, recheck your watch. Note the total time you spent with the patient’s initial care. If your initial time spent caring for the patient is 15-20 minutes or greater, keep this in mind. Cases such as these have a high likelihood of qualifying for critical care

Later, once you return to that patient’s care, repeat the above and record your time. In the course of reviewing labs and imaging, performing your re-exam, discussing with the patient’s primary physician/consultants and charting all of this time adds up. Now examine your aggregate time. If the encounter involved a patient with a “high probability of imminent or life threatening deterioration” and you reached 30 minutes, you can bill for Critical Care. Try tracking your time just once — you’ll be surprised.

Keeping track of our time in Emergency Medicine may run counter-intuitive to our training and instincts. However, at the end of the day, the onus is on us clinicians to accomplish what only we can do. Your time is valuable in Emergency Medicine — be sure to take note as your optimal reimbursement depends on it.

How Your Documentation Should Look

“I spent 45 minutes of critical care time with this patient. This does not include time spent on separately reported billable procedures.”

Following CMS fraud guidelines, some payers require charting that specifies an exact time rather than just a range of minutes. Therefore, strive to be as specific as possible (i.e. specify “45 minutes” rather than “30 to 74 minutes”). This is considered best-practice. Strive to generate charts that are distinct and reflect the service you provide.

It is essential to have a proper Critical Care statement to excel in your reimbursement. With your next ER shift, you may be the pivotal provider whose actions save someone’s life. The diagnostic and therapeutic interventions you deliver may result in extraordinary care. However, without your appropriate charting, the proper reimbursement for your services will go nowhere. In regard to optimizing your revenue, when the encounter warrants, you must to provide a Critical Care statement.

3 Pearls for Your Successful Reimbursement

Recall “30 Minutes” with Critical Care: It’s the marquee time in regards to billing.

Be Mindful of Your Time: Take credit for the Critical Care service you provide.

The next article in this three-part series on Critical Care reimbursement will cover “All That It Is” and “All It is Not.” You’ll learn how to master the foundational building blocks of Critical Care time. Its unique content will also show you how to avoid the pitfalls. Find out what it takes to excel in your reimbursement. In the weeks ahead, apply what you’ve learned. Stay vigilant and the merits will follow. Your proper documentation facilitates your best results.

Dan Magdziarz, DO, is an emergency physician at Palos Hospital in Chicagoland. He is also CEO and founder of ChartOptima.com: 2018 Emergency Medicine reimbursement teaching website. You can follow on Twitter @EMreimbursement. Share your interests and comments: dmagdziarz@chartoptima.com.

“I was entranced by an essay in Emergency Physicians Monthly . . . If you want to know what professional craftsmanship looks like, this is it. ”

-David Brooks, New York Times Op/Ed Editor

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